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20 Feb Ask the Expert: Multiple Medications for Migraine Attacks

Q. My doctor prescribed several medications for my migraine attacks, including naproxen tablets, zolmitriptan nasal spray and droperidol injections. Which medication should I use first?

A. Your healthcare provider is wise to prescribe multiple treatment choices. All migraine patients should have at least two medication options for their attacks. Unfortunately, far too many people only have one drug and end up suffering in instances when the drug does not help.

Deciding how quickly you need your medication to take action is probably the best way to approach this question. In terms of speed of onset of action, the rankings are:

Injectable

Nasal spray

Pill/tablet

For example, if you awake in the morning with a severe attack, then you obviously want a drug that will have effects as fast as possible. In this case, your injection would be your best choice, although your nasal spray could also be an option. On the other hand, if during the day you feel an attack slowly building and know that later in the day you will have significant pain, a pill would be a reasonable first choice.

Another important consideration is when to use an additional drug if the first medication fails to provide relief. As a general rule, shots and nasal sprays reach full effect within one to two hours, while medications taken by mouth need two to four hours. Thus, you should wait at least the appropriate amount of time to ensure that the medication has had a chance to work prior to consuming another medication.

Here are some other factors to consider. Pills and tablets are clearly poor choices if you have nausea and vomiting; a shot, nasal spray or even a suppository would be better. A drug’s side effects are important. For example, a medication that makes you drowsy is obviously a poor option if you need to be fully alert to perform work or other important tasks (like driving). However, this medication may work well if you are about to go to bed anyway. With time you will undoubtedly gain the experience needed to match the appropriate medication for your particular needs at a specific moment.